N.J. Admin. Code § 8:43A-9.3

Current through Register Vol. 56, No. 17, September 3, 2024

Section 8:43A-9.3 - Policies and procedures

(a) The facility shall develop and implement written policies and procedures, approved by the patient care policy committee, for the administration, control, and storage of medications. The patient care policy committee shall review the policies and procedures and document the review at least annually.

(b) The facility's policies and procedures for the administration, control, and storage of medications shall include, but not be limited to, policies and procedures for the following;

1. Documenting and reviewing adverse drug reactions and medication errors;

2. Discontinuing drug orders, including, but not limited to, the length of time drug orders may be in effect, for drugs not specifically limited as to duration of use or number of doses when ordered, including intravenous infusion solutions;

3. The control of the administration of toxic and dangerous drugs, including at least narcotics, sedatives, anticoagulants, antibiotics, oxytoxics, corticosteroid products, intravenous infusion solutions, and other drugs specified in the facility's policies and procedures;

4. The use of parenterals, if used, including the labeling of intravenous infusion solutions, such that a supplementary label is affixed to the container of any intravenous infusion solution to which drugs are added;

5. The purchase, storage, safeguarding, accountability, use, and disposition of drugs, in accordance with the New Jersey State Board of Pharmacy Rules, N.J.A.C. 13:39, and the Controlled Dangerous Substances Acts and amendments thereto. Pharmaceutical services provided through written agreement shall be provided by a pharmacy licensed by the New Jersey State Board of Pharmacy. An individual patient may choose to obtain medications from a pharmacy which is not located in New Jersey;

6. The procurement, storage, use, and disposition of needles and syringes in accordance with all applicable Federal and State laws and rules, including those specified at N.J.A.C. 8:43A-14.6(b). All needles and syringes shall be kept in locked storage areas;

7. The control of drugs subject to the Controlled Dangerous Substances Acts and amendments thereto, in compliance with the New Jersey State Board of Pharmacy Rules, N.J.A.C. 13:39, and all other Federal and State laws and regulations concerning procurement, storage, dispensing, administration, and disposition. Such policies and procedures shall include, but not be limited to, the following:

i. Provision for a verifiable record system for controlled drugs;

ii. Policies and procedures to be followed in the event that the inventories of controlled drugs cannot be verified or drugs are lost, contaminated, unintentionally wasted, or destroyed. A report of any such incident shall be written and signed by the persons involved and any witnesses present; and

iii. In all areas of the facility where drugs are dispensed, administered, or stored, procedures for the intentional wasting of controlled drugs, including the disposition of partial doses, and for documentation, including the signature of a second person who shall witness the disposition;

8. The security of the keys or codes to locked drug storage areas, including specification of the personnel who may retain the keys or security codes. Only licensed nursing or medical personnel shall retain the keys or security codes to storage areas in which drugs subject to the Controlled Dangerous Substances Acts and amendments thereto are kept;

9. The control and limitation of use of drugs marked "sample";

10. The maintenance of records of prescribers' Controlled Dangerous Substance registration numbers and Drug Enforcement Administration registration numbers for New Jersey; and

11. Up-to-date pharmaceutical reference materials to be provided at locations specified in the facility's policies and procedures and made available to medical and nursing staff.

i. The telephone number of the designated Statewide or regional New Jersey Poison Information and Education System (1-800- 222-1222) shall be provided at locations specified in the facility's policies and procedures.

ii. Current Federal and State drug law information shall be available to the pharmaceutical service.

iii. A list of abbreviations, metric apothecary conversion charts, and a list of chemical symbols, approved by the medical staff, shall be kept in areas where medications are prepared for administration.

N.J. Admin. Code § 8:43A-9.3

Amended by 54 N.J.R. 60(a), effective 1/3/2022